Intake Questionnaire

15 Jun Intake Questionnaire

Complete the intake assessment form you developed earlier in the course. Fill in as much of the data as you can from the facts of the case. Then, create your diagnostic impressions, selecting at least three possible diagnoses you would consider for this case. (NFL Star Brandon Marshall)

Finally, write a brief assessment plan that would enable you to gather further evaluation data. It should include at least four separate sources or methods of data collection.

Client Intake Questionnaire

Please fill in the information below and bring it with you to your first session.

Please note: information provided on this form is protected as confidential information.

Personal Information

Name:________________________Brandon Marshall ________________________ Date: ______________________

Parent/Legal Guardian (if under 18): ___________________________________________________

Address: _________________________________________________________________________

Home Phone: ___ _______________________________ May we leave a message? □ Yes □ No

Cell/Work/Other Phone: _________________________ May we leave a message? □ Yes □ No

Email: ________________________________________ May we leave a message? □ Yes □ No *Please note: Email correspondence is not considered to be a confidential medium of communication. DOB: ______________________________ Age: _______ Gender: ________________ Martial Status:

□ Never Married □ Domestic Partnership □ Married

□ Separated □ Divorced □ Widowed

Referred By (if any): ________________________________________________________________

History

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?

□ No □ Yes, previous therapist/practitioner: _________________________________________

Are you currently taking any prescription medication? □ Yes □ No

If yes, please list:

__________________________________________________________________________________

__________________________________________________________________________________

Have you ever been prescribed psychiatric medication? □ Yes □ No

If yes, please list and provide dates:

_________________________________________________________________________________ _________________________________________________________________________________

General and Mental Health Information

1. How would you rate your current physical health? (Please circle one)

Poor Unsatisfactory Satisfactory Good Very good

Please list any specific health problems you are currently experiencing: _____________________

_____________________________________________________________________________

2. How would you rate your current sleeping habits? (Please circle one)

Poor Unsatisfactory Satisfactory Good Very good

Please list any specific sleep problems you are currently experiencing:

__________________________________________________________________________________

__________________________________________________________________________________

3. How many times per week do you generally exercise? ___________________________________What types of exercise do you participate in? ____________________________________________

4. Please list any difficulties you experience with your appetite or eating problems: ______________________________________________________________________________________________

5. Are you currently experiencing overwhelming sadness, grief or depression? □ No □ Yes

If yes, for approximately how long?___________________________________________________

6. Are you currently experiencing anxiety, panics attacks or have any phobias? □ No □ Yes

If yes, when did you begin experiencing this? ___________________________________________

7. Are you currently experiencing any chronic pain? □ No □ Yes

If yes, please describe: _____________________________________________________________

8. Do you drink alcohol more than once a week? □ No □ Yes

9. How often do you engage in recreational drug use?

□ Daily □ Weekly □ Monthly □ Infrequently □ Never

10. Are you currently in a romantic relationship? □ No □ Yes

If yes, for how long? _______________________________________________________________

On a scale of 1-10 (with 1 being poor and 10 being exceptional), how would you rate your relationship? ______________________________________________________________________________

11. What significant life changes or stressful events have you experienced recently? _____________

______________________________________________________________________________ ______________________________________________________________________________

Family Mental Health History

In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (e.g. father, grandmother, uncle, etc.)

Please Circle List Family Member

Alcohol/Substance Abuse yes / no _______________________

Anxiety yes / no _______________________

Depression yes / no _______________________

Domestic Violence yes / no _______________________

Eating Disorders yes / no _______________________

Obesity yes / no _______________________

Obsessive Compulsive Behavior yes / no _______________________

Schizophrenia yes / no _______________________

Suicide Attempts yes / no _______________________

Additional Information

1. Are you currently employed? □ No □ Yes

If yes, what is your current employment situation? _________________________________________ __________________________________________________________________________________

Do you enjoy your work? Is there anything stressful about your current work? ___________________

__________________________________________________________________________________

__________________________________________________________________________________

2. Do you consider yourself to be spiritual or religious? □ No □ Yes

If yes, describe your faith or belief: _____________________________________________________

__________________________________________________________________________________

3. What do you consider to be some of your strengths? ______________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

4. What do you consider to be some of your weaknesses? ____________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

5. What would you like to accomplish out of your time in therapy? ____________________________

__________________________________________________________________________________

Case Diagnostic Exercise Template

Case Name: Anxiety Disorder

Diagnoses Considered:

1.

2.

3.

Assessment Plan:

Sources of Clinical Data:

1.

2.

3.

4.